The synthetic opioid fentanyl and its even-more-powerful cousins are here to stay. They are also increasingly likely to be accompanied by methamphetamine, a powerful stimulant drug that has affected much of the rest of the country but has spared the Northeast until recently. In spite of this grim outlook, we have several evidenced-based options to get a handle on the challenges faced by individuals with substance use disorder in Boston.
We have effective treatment available in the form of medication for opioid use disorders. In addition to methadone and buprenorphine (which is often called by one of its brand names, Suboxone), there is a newer option: injectable buprenorphine, which lasts for a month and eliminates concerns about medication diversion. All of these options save lives and prevent HIV, hepatitis, and other terrible consequences of opioid use. We must make them easily accessible to every person who is ready to accept treatment. The state should enforce requirements that all residential and inpatient facilities routinely offer these medications, and we need to greatly increase their availability in the outpatient setting and in criminal justice settings in order to provide ongoing care. Recent news suggests that we may also have medication options for methamphetamine, with a study this month showing some benefit from the antidepressant medication mirtazapine (Coffin, JAMA psychiatry, 12/19).
Medication alone is not enough to address the devastation that follows addiction, and we need to increase the availability of effective, evidence-based counseling interventions. This is critical for developing skills for relapse prevention, re-engaging with other sources of reward, and for addressing the depression, anxiety, and PTSD that so often accompany severe addiction.
We also need to increase the trained workforce at all levels. We need more master’s-level trained counselors and social workers with specific training in addiction treatment, and we need to pay them a competitive salary so that they can afford to work with our most vulnerable and high-need patients. Addiction Medicine and Addiction Psychiatry fellowships are increasing the supply of expert physicians, and large numbers of nurse practitioners and physician assistants are choosing to take the training that allows them to prescribe medications for opioid use disorder. Nurses continue to play a critical role in promoting access to treatment (Labelle, J Subst Abuse Treatment, 2016), and recovery coaches are increasingly being recognized as an important part of the workforce (Welch, AJPH, 2019). A 12-hospital consortium, led by Kate Walsh of BMC and Elizabeth Nabel of Brigham Health, is catalyzing addiction treatment training and stigma reduction in hospitals in eastern Mass. We hope that this will expand to hospitals and health systems across the commonwealth.
Housing is a critical component of addiction treatment. Becoming sober is difficult enough, but when folks are also homeless, the challenges are often insurmountable. Shelter care is not enough, and we need to greatly expand programs like Pine Street Inn’s permanent supportive housing program that helps people obtain housing and stay housed.
Finally, we need to help our neighbors who are not yet in recovery to stay alive and avoid devastating infections. Efforts such as overdose education and naloxone distribution have had an impact in reducing overdose deaths. Syringe exchange has helped to decrease infections. We need to continue to expand these services. We also need to provide widespread access to safe injection facilities in order to prevent harm and engage our most vulnerable neighbors in a supportive environment that can lead to addiction treatment and recovery. A recent study found that more than half of the people who died of drug overdose in Massachusetts had had indicators that they were at high risk for overdose during contact with the health care or criminal justice system in the 12 months prior to their deaths (Larochelle, Drug and Alcohol Dependence, 2019). Let’s make sure that we take every opportunity to save a life.
Dr. Miriam Komaromy was named medical director of the Grayken Center for Addiction at Boston Medical Center in August 2019. Previously, Komaromy led the Extension for Community Heathcare Outcomes Institute’s programs for addiction and psychiatry in Albuquerque, New Mexico. She also serves on the American Society of Addiction Medicine’s National Board of Directors.